Waters Of Covington, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Covington, Indiana.
- Location
- 1600 E Liberty St, Covington, Indiana 47932
- CMS Provider Number
- 155223
- Inspections on file
- 34
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 30 (2 serious)
Citation history
Health deficiencies cited at Waters Of Covington, The during CMS and state inspections, most recent first.
A resident with a history of constipation and acute pain repeatedly requested to be sent to the hospital, but staff, including an LPN and RN, failed to assess or act on his reports despite multiple notifications from CNAs and a housekeeper. The resident's pain and requests were dismissed, and only after a family member intervened was the resident sent to the hospital, where he required operative intervention for severe fecal impaction and was diagnosed with gallbladder cancer.
A resident with a history of constipation experienced several days without a bowel movement and reported escalating pain, but staff failed to perform timely assessments, notify the physician, or document effective interventions. Despite repeated complaints and ineffective PRN medications, the resident's condition worsened until a family member intervened, resulting in hospital transfer and operative intervention for severe fecal impaction. Additional record reviews showed similar delays and inconsistencies in bowel management for other residents.
The facility failed to properly assess and safely transfer residents using mechanical lifts, resulting in a resident sustaining a right tibia fracture after falling from an improperly sized sling. Staff were not adequately trained on sling selection, and slings were ordered based only on weight, not manufacturer guidelines. Another resident was transferred without proper documentation or adherence to safety procedures, and a third resident with multiple falls did not receive updated preventive interventions. Employee files also lacked documentation of mechanical lift competency evaluations.
Staff failed to demonstrate competency in mechanical lift transfers, resulting in incidents where two residents were improperly transferred—one of whom fell and sustained a fracture. Staff were unclear on selecting the correct sling size and type, did not consistently follow safety procedures such as locking wheelchairs and lifts, and lacked adequate training on manufacturer guidelines and facility policy. These deficiencies placed all residents requiring mechanical lift transfers at risk.
A resident with severe cognitive impairment suffered a fall during a mechanical lift transfer, resulting in a right tibia fracture. Although the initial incident was reported to the family, the resident's POA was not notified of the fracture until the day after it was discovered, contrary to facility policy requiring timely notification of significant changes in condition.
The facility failed to provide adequate ADL assistance, as observed with residents having unkempt nails and facial hair, and insufficient showers. Despite care plans requiring regular grooming and hygiene, several residents were not properly attended to, with documentation showing inconsistencies in shower schedules. Staff interviews revealed a lack of awareness and adherence to the facility's ADL care policy.
A facility failed to notify a resident's representative of significant changes in condition and treatment, including incidents, transfers, and medication changes. The resident, on hospice services, had multiple instances where the Power of Attorney was not informed, contrary to facility policy. Staff interviews confirmed the expectation of notification, but documentation was lacking.
A resident with vascular dementia was transferred to a Behavioral Health Care hospital following an incident of inappropriate behavior, but the facility failed to complete and provide the necessary transfer and discharge documents to the resident's representative. The facility's policy required such documentation, but it was not followed, and the documents were not found in the resident's medical record.
A facility failed to provide bed hold documentation to a resident's representative during a hospital transfer. The resident, diagnosed with vascular dementia, was transferred to a BHC hospital after an incident of inappropriate behavior. The facility could not locate the required bed hold documents, which should have been completed and provided to the resident's representative, as per facility policy.
The facility failed to conduct timely care plan meetings for two residents, leading to a deficiency in care planning. One resident with multiple sclerosis had not had a meeting since February, and another with a history of cerebral infarction had not had a meeting since June. The Social Services Director was unaware of these lapses and did not document reasons for non-attendance or proceed with meetings without the residents or their representatives.
A facility failed to prevent a catheter bag from contacting the floor, posing an infection risk for a resident with a UTI. Additionally, discrepancies in urine output documentation for two residents with catheters were noted, potentially impacting care. Staff interviews revealed communication and documentation issues, with CNAs responsible for relaying output information to nurses, leading to inconsistencies.
A facility failed to properly label and date an opened bottle of tube feeding formula for a resident with severe cognitive impairment and multiple medical conditions. An LPN used a partially empty bottle for the resident's feeding without knowing when it was opened, violating the facility's policy. Another bottle was found labeled with the date and initials but lacked the time of opening, which the DON confirmed was necessary. The facility's policy on enteral tube feeding was not followed, increasing the risk of microbial contamination.
A facility failed to address a pharmacy recommendation for a dose reduction of Zoloft for a resident with depression and other conditions. Despite a recommendation to reduce the dose and document the resident's status, there was no response from the provider. Interviews with the DON and RNC confirmed the oversight, and the facility's policy requiring action on pharmacy recommendations was not followed.
The facility failed to maintain food safety and hygiene standards, as observed during a kitchen tour. A staff member was seen preparing food without a hair restraint covering his mustache, violating the facility's policy. Additionally, raw and cooked meats were improperly stored together, and expired food items were not discarded as required. The Dietary Manager acknowledged these lapses in adherence to the facility's policies.
The facility failed to maintain and document respiratory equipment properly for several residents. Observations showed undated and improperly stored oxygen tubing and nebulizer equipment, with some residents lacking documented orders for oxygen administration. Staff interviews confirmed that equipment should be dated and bagged weekly, but the facility's policy was undated, and staff did not adhere to it.
The facility failed to provide alternative hydration choices for residents, affecting all 81 residents who relied on the kitchen for drinks. Staff were instructed not to make coffee on the units due to temperature concerns, leading to the removal of coffee supplies and limiting residents' access to preferred drinks. The facility's hydration management policy, which required fluids to be offered at various times, was not followed, as only ice water was provided.
A resident with diabetes did not receive prescribed Sitagliptin-metformin HCL on multiple occasions due to the facility's failure to obtain the medication and notify the physician of missed doses. Interviews with staff revealed that established procedures for handling unavailable medications were not followed, leading to this deficiency.
The facility failed to report a resident's allegations of abuse and did not accurately document the investigation of bruising and a laceration. The resident was found with extensive bruising and a laceration, and the allegations were not reported to state authorities. The final report lacked detailed documentation and did not include the suspension of the CNA involved.
The facility failed to document and follow up on falls, injuries, and abuse allegations for three residents. One resident had multiple bruises and a laceration with no immediate follow-up or root cause identified. Another resident had repeated falls with incomplete documentation and follow-up. A third resident reported abuse, but the facility did not document follow-up or psychosocial support. Staff interviews revealed inconsistencies in the facility's process for assessing and documenting these incidents.
Failure to Respond to Resident's Acute Pain and Requests for Hospital Transfer
Penalty
Summary
A resident who was cognitively intact and dependent on staff for mobility and toileting experienced acute pain and repeatedly requested to be sent to the hospital. Over the course of the night and morning shifts, multiple staff members, including CNAs and a housekeeper, observed the resident in distress and reported his condition and requests for help to nursing staff. Despite these repeated reports, the LPN on the night shift and the RN on the morning shift failed to adequately assess the resident, provide timely interventions, or notify a physician of the resident's change in condition. The resident's pain and requests for hospital transfer were dismissed or ignored, with staff making comments that minimized the resident's complaints. The resident's medical record indicated a history of constipation, with a recent KUB scan confirming constipation and ineffective results from prescribed stool softeners and laxatives. The resident had not had a bowel movement for several days, and there was no documentation of new interventions following the scan results. On the morning in question, the resident was observed screaming in pain, and his family member, after being on the phone with him for over 45 minutes, called the facility directly to demand that he be sent to the hospital. Only after this intervention from the family and notification to facility management was the resident transferred to the hospital, where he required operative intervention for a severe fecal impaction and was diagnosed with gallbladder cancer. Interviews with staff revealed that the resident's pain and requests for help were widely known throughout the facility, yet the nurses responsible did not take appropriate action. The LPN did not assess vital signs or notify the physician, and the RN delayed seeing the resident, prioritizing medication pass and expressing frustration at the resident's repeated calls for help. The lack of timely assessment and intervention resulted in prolonged pain and delayed treatment for the resident.
Failure to Timely Monitor and Treat Constipation Leading to Severe Fecal Impaction
Penalty
Summary
The facility failed to provide timely monitoring and treatment for a resident with a history of constipation who had not had a bowel movement for several days and was experiencing pain. Despite the resident's repeated complaints of pain and lack of bowel movements, staff did not perform adequate assessments, did not notify the physician of the resident's change in condition, and did not document interventions or their effectiveness. The resident received PRN medications for constipation that were documented as ineffective, but no further action was taken, and the resident's pain continued to escalate without appropriate response from nursing staff. Multiple staff members, including CNAs and nurses, were made aware of the resident's ongoing pain and requests for help, but failed to conduct timely assessments or escalate care. The resident's family ultimately intervened after hearing the resident in distress, leading to the resident being sent to the hospital, where a severe fecal impaction was discovered, requiring operative intervention under anesthesia. The medical record lacked documentation of physical assessments, physician notifications, and timely interventions in response to the resident's symptoms and ineffective medications. Additionally, the facility failed to implement an effective protocol for ongoing monitoring of bowel management for multiple residents. Reviews of other residents' records revealed delays in administering interventions for constipation, lack of timely assessments, and inconsistent documentation of bowel movements and physician notifications. The facility's bowel management program was not consistently followed, resulting in delayed care and potential harm to residents with constipation or at risk for bowel irregularity.
Removal Plan
- Reviewed and revised a new bowel procedure/protocol in collaboration with the Medical Director.
- Educated all nursing staff on the new policy.
- Implemented the new protocol.
- Conducted a complete audit of residents' records for the need and/or continued use of Milk of Magnesia (M.O.M.) and other bowel management medications.
- Confirmed orders with the Medical Director.
- Established a process where if a resident flagged on the EMAR dashboard as not having had a BM after 72 hours, they should receive a dose of MOM.
- Required that if a resident had not had a BM by the end of that nurse's shift, the physician would be notified and report given to the oncoming nurse.
- Ensured systemic plan for education and monitoring of staff to ensure staff assessed and monitored residents for pain and change in condition, and that staff followed the facility bowel protocol.
Failure to Ensure Safe Mechanical Lift Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure residents were properly assessed for and safely transferred using mechanical lifts, resulting in actual harm to a resident who fell from a mechanical lift sling and sustained a right tibia fracture. The resident, who had cerebral palsy and severe cognitive impairment, was dependent on staff for transfers and had a history of falls. During a transfer, the resident became restless and slid out of a mechanical lift sling that was not appropriately sized or compatible with the lift, as staff were not trained on sling selection or sizing. The medical record lacked documentation of a mechanical lift assessment for the resident, and staff interviews revealed confusion about sling types and sizing, with slings being ordered based solely on weight and not in accordance with manufacturer recommendations. Another resident was transferred using a mechanical lift without a physician's order or care plan documentation for mechanical lift use. During observation, staff failed to lock the wheelchair and the mechanical lift brakes during the transfer, and the sling was not properly positioned, with the pad extending several inches above the resident's head. These actions demonstrated a lack of adherence to safe transfer procedures and mechanical lift manufacturer guidelines. A third resident with a history of multiple falls did not have new preventive interventions implemented after each fall, despite repeated incidents and high fall risk scores. The care plan was not updated with new interventions following each fall, contrary to facility policy. Additionally, review of employee files showed a lack of documented competency evaluations for mechanical lift use among recently hired staff. These deficiencies contributed to unsafe conditions and inadequate supervision to prevent accidents.
Failure to Ensure Staff Competency in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competencies in performing mechanical lift transfers, as evidenced by multiple observed incidents involving two residents who required such transfers. In one case, a resident with severe cognitive impairment, cerebral palsy, and a recent major injury was transferred using a mechanical lift by two CNAs. During the transfer, the resident became restless and maneuvered herself out of the sling, resulting in a fall and a right tibia fracture. Staff interviews and documentation revealed that the CNAs were not adequately trained on selecting the correct sling type or size, and there was confusion regarding the compatibility of slings with the mechanical lift equipment. The slings used were sometimes not appropriate for the resident's needs, and staff were unclear on how to support the resident's fractured leg during transfers. In another observed incident, a resident was transferred from a wheelchair to a bed using a mechanical lift. During this process, the CNA failed to lock the wheelchair and the mechanical lift prior to transferring and lowering the resident, respectively. Additionally, the staff involved were unable to determine the correct size of the lift pad for the resident, and there was no physician order documented for the use of a mechanical lift for this resident. Observations also noted that some mechanical lift slings were not labeled with resident names, and staff reported using slings that were not always the correct size or type due to lack of training or availability. Interviews with various staff members, including CNAs and QMAs, confirmed a lack of knowledge and training regarding the selection and use of mechanical lift slings, as well as the proper procedures for safe transfers. Staff were not consistently aware of manufacturer guidelines, facility policies, or the specific needs of residents during mechanical lift transfers. These deficiencies in staff competency and adherence to policy had the potential to affect all residents requiring mechanical lift transfers in the facility.
Delayed Family Notification of Resident Fracture
Penalty
Summary
A resident with cerebral palsy and severe cognitive impairment experienced a fall during a mechanical lift transfer, resulting in the resident sliding out of the lift sling and landing on her right side. The incident was witnessed by two CNAs, and the resident was assessed by a nurse and a nurse practitioner, who determined she could be moved and later assisted her to lunch. The resident's family member was notified of the initial incident. Subsequently, x-rays were ordered and completed, revealing a right tibia fracture. The physician was notified, and appropriate medical interventions were initiated, including a splint and an orthopedic referral. Despite the discovery of the fracture, there was no documentation that the resident's Power of Attorney (POA) or family member was notified of the new injury on the day it was identified. The record shows that the POA was not informed of the fracture until the following day, contrary to facility policy requiring timely notification of a resident's representative in the event of an injury or significant change in condition. The delay in notification was confirmed during an interview with the DON, who discovered the lapse during a morning meeting and subsequently ensured the family was informed.
Deficiencies in ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for several residents, as observed during a survey. Resident B was found with long, jagged nails containing dark debris, despite having a care plan that required daily ADL assistance. Resident E, who was cognitively intact but required extensive assistance, was observed with multiple chin hairs, indicating a lack of personal hygiene care. Similarly, Residents F and G, both with severe cognitive impairments, were also observed with multiple chin hairs, suggesting a failure in providing necessary grooming assistance. Resident D's care was also found lacking, as the facility failed to provide the preferred number of showers. Despite a care plan indicating a preference for showers twice a week, documentation showed Resident D received only three showers over a 30-day period. This discrepancy was highlighted by a grievance from Resident D's family, expressing concerns about the adequacy of his showers and personal hygiene. Interviews with staff revealed inconsistencies in the documentation and execution of shower schedules, with the Director of Nursing unaware of any complaints regarding shower preferences. The facility's policy on ADL care, which includes personal hygiene tasks such as shaving and nail care, was not adhered to, as evidenced by the observations and interviews. The Director of Nursing confirmed that residents should be shaved and have their nails cut on shower days, yet this was not consistently practiced. The lack of proper documentation and adherence to care plans contributed to the deficiencies observed in the care provided to the residents.
Failure to Notify Resident's Representative of Changes in Condition
Penalty
Summary
The facility failed to notify a resident's representative of changes in condition and treatment for Resident B, who was on hospice services. The Power of Attorney (POA) for Resident B was not informed of several significant changes, including an incident between Resident B and another resident, a transfer to a psychiatric facility, medication changes, and the resident being placed in isolation. The hospice agency was also not informed of the transfer order. Resident B's medical record indicated multiple instances where the POA was not notified of changes in condition or treatment. These included a chest x-ray and subsequent antibiotic administration, a change in condition requiring intravenous fluids, and a transfer to the hospital emergency room for evaluation and treatment. The facility's policy required notification of the resident's representative in such cases, but documentation of these notifications was lacking. Interviews with facility staff, including a Qualified Medication Aide, a Registered Nurse, and the Director of Nursing, revealed that the standard procedure was to notify the family or responsible party of changes in condition. However, the documentation did not reflect that these notifications were made. The facility's policy documents, provided by the Director of Nursing, outlined the requirement for notifying the resident's representative of significant changes, but these procedures were not followed in the case of Resident B.
Failure to Provide Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure that transfer and discharge documents were completed and provided to a resident's representative for a discharge to the hospital. This deficiency was identified for a resident with vascular dementia, who was involved in an incident where they exhibited socially inappropriate behavior towards another resident. Following this incident, the resident was referred to a Behavioral Health Care (BHC) hospital, but the facility did not have documentation of a physician's order for this transfer. Additionally, the facility's records lacked the necessary transfer and discharge forms that should have been completed and provided to the resident's representative. During an interview, a Regional Clinical Consultant confirmed that the facility was unable to locate these documents, which were required to be completed and included in the resident's medical record. The facility's policy indicated that notice should be given to the resident or responsible party before a transfer to a hospital, but this procedure was not followed in this case.
Failure to Provide Bed Hold Documentation for Hospital Transfer
Penalty
Summary
The facility failed to ensure that bed hold documents were completed and provided to a resident's representative during a transfer to a hospital. This deficiency was identified for a resident diagnosed with vascular dementia, who was transferred to a Behavioral Health Care (BHC) hospital following an incident involving inappropriate behavior. The resident's record lacked documentation of a bed hold policy being completed and provided to the resident's representative, which is a requirement prior to hospital transfer. During the review, it was noted that the facility was unable to locate the completed bed hold policy documents for the resident's transfer. The facility's policy mandates that information regarding the resident's bed status and how the bed will be held should be provided to the resident or their representative, and a copy should be placed in the resident's medical record. However, this was not done, as confirmed by the Regional Clinical Consultant during an interview.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to conduct timely care plan meetings for two residents, leading to a deficiency in care planning. Resident 44, who has multiple sclerosis and adult failure to thrive, had not had a care plan meeting since February, despite a quarterly MDS assessment in July indicating a moderate cognitive deficit. The Social Services Director (SSD) was unaware of the missed meeting and did not document the reasons for the absence of the resident and her representative. A planned meeting in August was not held because the resident and family did not plan to attend, and the SSD did not know that meetings could proceed without them. Similarly, Resident 76, with a history of cerebral infarction and no cognitive deficit, had not had a care plan meeting since June. The SSD, new to her position, was unaware of this lapse and had planned a meeting for September, but had not received confirmation from the resident or family. The SSD did not document the resident's decision to decline attendance and was unaware that meetings could occur without the resident or representative. The facility's policy requires documentation of notifications and attendance, which was not followed in these cases.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper handling of a resident's indwelling urinary catheter bag, which was observed lying flat on the floor, exposing it to potential infection risks. This deficiency was noted during a random observation of a resident who had an active urinary tract infection (UTI) and was receiving antibiotic treatment. The facility's policy, as indicated by the Regional Clinical Consultant, mandates that catheter tubing and drainage bags should not come into contact with the floor to prevent infection control risks. Additionally, the facility failed to maintain accurate documentation of urine output for two residents with indwelling urinary catheters. Significant discrepancies were found between the Point of Care (POC) task forms completed by Certified Nursing Assistants (CNAs) and the Treatment Administration Records (TARs). These discrepancies in recorded urine output amounts could potentially impact the residents' care, as accurate measurement is crucial for monitoring their condition and preventing complications. Interviews with facility staff revealed a lack of clear communication and documentation procedures regarding urine output measurements. CNAs were responsible for emptying catheter drainage bags and relaying the information to nurses, but inconsistencies in documentation locations within the computer system contributed to the discrepancies. The facility's policy emphasized the need for accurate measurement of urinary output and ongoing monitoring of catheter-related issues, highlighting the importance of adherence to these protocols to prevent UTIs and ensure proper resident care.
Improper Labeling of Tube Feeding Formula
Penalty
Summary
The facility failed to ensure proper labeling and dating of an opened bottle of tube feeding formula for a resident with a feeding tube. During an observation, two bottles of Glucerna formula were found on the bedside table of a resident with severe cognitive impairment and multiple medical conditions, including dysphagia and obstructive hydrocephalus. One bottle was full, and the other was partially used, but neither was labeled or dated. An LPN admitted to using the partially empty bottle for the resident's bolus feeding without knowing when it was opened, which violated the facility's policy requiring opened formulas to be labeled with the date, expiration, and initials. Further observations revealed another bottle of Glucerna on the resident's bedside table, which was labeled with the date and initials but lacked the time it was opened. The Director of Nursing confirmed that the bottle should have included the time of opening, as the formula is only good for a specified period after being opened. The facility's policy on enteral tube feeding and the specific instructions for using Glucerna 1.2 Cal were not followed, increasing the potential for microbial contamination due to improper handling and labeling of the feeding formula.
Failure to Address Pharmacy Recommendation for Dose Reduction
Penalty
Summary
The facility failed to address a pharmacy recommendation for a resident regarding the administration of Zoloft (sertraline) for depression. The resident, who had diagnoses including depressive episodes, insomnia, cognitive communication deficit, disorientation, and hallucinations, was on a daily dose of 50 mg of Zoloft. A pharmacy review conducted by Pharmacy Management Solutions recommended a dose reduction to 25 mg and requested documentation of the resident's current mental and behavior status, or a detailed reason for not reducing the dose. However, there was no documentation of a response from the provider to this recommendation. Interviews with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) revealed that the pharmacy review had not been addressed, and neither could provide an explanation or additional documentation indicating that the recommendation was acted upon. The facility's policy required that any recommendations from the consultant pharmacist be reported to the attending physician, DON, and medical director, and that each recommendation must be acted upon. The lack of response to the pharmacy's recommendation constituted a failure to comply with this policy.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards during kitchen operations. During a kitchen tour, it was observed that a staff member was preparing food without covering his mustache with a hair restraint, which is against the facility's policy. This was noted on two separate occasions, and the Dietary Manager (DM) acknowledged that facial hair should be covered. Additionally, the facility's policy on personal appearance mandates the use of hairnets, hair restraints, and beard guards, which was not followed in this instance. Furthermore, the facility did not ensure proper storage of potentially hazardous foods. In the walk-in refrigerator, raw beef and pork were found thawing together in a pan, with cooked beef stored on the same shelf, contrary to the facility's food storage policy. The DM confirmed that raw and cooked meats should not be stored together. Additionally, expired food items, such as loaves of bread, were found in various pantries, which should have been discarded according to the facility's date marking policy. The DM indicated that the night dietary aides were responsible for monitoring expiration dates, but this was not effectively carried out.
Improper Maintenance and Documentation of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper maintenance and documentation of respiratory equipment for eight residents requiring respiratory care. Observations revealed that oxygen tubing and nebulizer equipment were not consistently dated, bagged, or stored appropriately. For instance, Resident J's oxygen tubing was dated three months prior, and Resident K's oxygen tubing lacked a date, with an empty humidity bottle attached to the concentrator dated several months earlier. Additionally, Resident H's nebulizer treatment set was unbagged, and Resident C's oxygen equipment was undated and improperly stored. Further observations indicated that some residents, such as Residents D, E, and F, had oxygen tubing lying unbagged on the floor, with no orders for oxygen administration documented in their medical records. Resident G's equipment storage bags were dated but lacked corresponding orders for oxygen administration. Interviews with facility staff, including a Qualified Medication Aide and the Assistant Director of Nursing, confirmed that oxygen equipment should be dated and bagged, with changes occurring weekly. However, the facility's policy on oxygen administration was undated, and the staff failed to adhere to the policy's requirements for labeling and maintaining respiratory equipment.
Failure to Provide Alternative Hydration Choices
Penalty
Summary
The facility failed to ensure that residents had access to alternative hydration choices for two out of the three days of the survey, affecting all 81 residents who received hydration from the kitchen. On one occasion, a Certified Nursing Aide (CNA) reported that the Dietary Manager (DM) instructed staff not to make coffee for residents on the units because it needed to be temperature-checked before serving. This decision led to the removal of coffee grounds from the units, preventing residents from having coffee when they desired, particularly in the mornings before the kitchen opened at 7 a.m. The lack of available drinks in the units' pantries was confirmed during an observation, where no drinks were found in the refrigerators, and coffee supplies were absent. The Dietary Manager explained that drinks, including coffee, were served when the kitchen opened, and the Director of Nursing (DON) had removed coffee from the units due to temperature concerns. Although individual containers of orange juice were purchased for the pantries, they were served during breakfast instead. The facility's policy on hydration management, provided by the Regional Nurse Consultant, outlined that fluids should be offered at various times, including mid-morning, mid-afternoon, and at bedtime, in addition to mealtimes and during medication administration. However, this policy was not adhered to, as staff only provided ice water and did not offer other drinks like coffee, which residents preferred.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide the necessary pharmaceutical services for Resident AA, who was admitted with diagnoses including type 2 diabetes mellitus, hypertension, and congestive heart failure. The resident had a physician's order for Sitagliptin-metformin HCL (Janumet) to be administered twice daily for diabetes management. However, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed medication on multiple occasions, specifically on 6/29/24, 6/30/24, 7/1/24, 7/2/24, and the morning dose on 7/3/24. The medical record lacked documentation of physician notification regarding these missed doses. Interviews with facility staff, including an LPN, an RN, and the Director of Nursing (DON), revealed that the standard procedure for unavailable medications involved checking the emergency drug supply and contacting the pharmacy for immediate delivery if necessary. Despite these protocols, the facility did not follow through with obtaining the medication or notifying the physician of the missed doses. The facility's policy on medication shortages outlined steps to be taken in such situations, but these were not adhered to, resulting in the deficiency noted in the report.
Failure to Report Allegations of Abuse and Incomplete Investigation Documentation
Penalty
Summary
The facility failed to ensure a resident's allegation of abuse and investigation of bruising were accurately reported. Resident B was found with bruising on bilateral arms, face, and chest, and a laceration on the lip. The initial report indicated the resident had swelling and bruising on her left hand and right arm, but the source of the bruising was not identified. An X-ray was ordered, and the resident was referred to social services. The investigation was completed without findings, and the resident's care plan was updated to reflect combative behavior with care. However, the follow-up report lacked detailed documentation of the extent of the bruising and the laceration on the lip, and it did not include the suspension of CNA 9 for five days pending the investigation. Witness statements revealed that on the day of the incident, the resident was heard screaming, and upon investigation, was found with bruising. The resident alleged that CNA 9 was trying to rape her, and the CNA was suspended for five days. However, the allegations of abuse were not reported to the state authorities. The ADM indicated that the extensive bruising and laceration were possibly caused by the resident being resistant to care and flailing her arms. The ADM also mentioned that the allegations of abuse were not reported because the resident had a history of PTSD from being raped. The facility's Abuse Prevention Policy requires employees to report any incident, allegation, or suspicion of abuse to the Administrator, who will then report it to the state authorities. The policy also mandates that all incidents be documented, and a final investigation report be completed within the required time frame. However, in this case, the facility failed to follow its policy, as the allegations of abuse were not reported, and the final report lacked detailed documentation and did not include the suspension of CNA 9.
Failure to Document and Follow Up on Falls, Injuries, and Abuse Allegations
Penalty
Summary
The facility failed to have a system in place for documentation of falls, non-pressure wounds, and injuries, and failed to ensure assessments and documentation were completed after falls, non-pressure wounds, and allegations of abuse were identified for three residents. Resident B was found with multiple bruises and a laceration on her lip, but the facility did not document the immediate follow-up treatment, root cause of the bruising, or notify the resident representative. Additionally, the care plan was not updated to reflect the resident's combative behavior, and there was no documentation of psychosocial support provided for seven days as ordered. Witness statements and interviews revealed inconsistencies and lack of proper documentation regarding the resident's injuries and the alleged abuse incident involving a CNA. Resident C had a history of falls and was found on the floor on multiple occasions. However, the facility failed to document 72-hour post-fall follow-up, notify the family representative at the time of the incidents, or complete a skin assessment for a bruise on the left hip. The resident's care plan included interventions for fall risk, but the documentation was incomplete and lacked follow-up on the resident's condition after the falls. Resident D reported being hit by a night shift CNA, but the facility's documentation lacked follow-up on the resident's allegations of abuse, psychosocial support for seven days, and updates to the care plan to reflect false allegations and racial slurs. The resident's record also lacked documentation of skin impairments found during the investigation. Interviews with staff indicated that the facility's process for assessing and documenting injuries, falls, and abuse allegations was not consistently followed, leading to incomplete and inadequate documentation of the residents' conditions and care.
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Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
The facility failed to ensure timely electronic transmission of MDS assessment data to CMS for a resident. Record review showed an annual MDS that was more than 120 days overdue for submission. The MDS coordinator reported that two care area assessments on the annual MDS had remained incomplete until just before surveyor review, at which time the MDS was finished and submitted. The Administrator acknowledged there was no facility policy in place governing MDS transmissions.
Surveyors found that MDS assessments were inaccurately coded for two residents. One resident with a prior Level II PASARR for serious mental illness was incorrectly coded on the Annual MDS as not having a serious mental illness or related condition. Another resident with generalized anxiety disorder, major depressive disorder, and dementia, who was receiving Lorazepam for anxiety, was not coded with an active anxiety disorder diagnosis on the Quarterly MDS, despite active orders documented on the MAR. The MDS coordinator acknowledged both coding errors, and leadership reported there was no facility-specific MDS policy, relying instead on the RAI manual.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Timely Transmit MDS Assessment Data to CMS
Penalty
Summary
The facility failed to ensure timely electronic transmission of MDS (Minimum Data Set) assessment data to the CMS system for one resident. Review of the clinical record for Resident 36 on 4/9/26 showed an annual MDS assessment dated 2/23/26 that was more than 120 days overdue for submission to CMS. During an interview on 4/10/26 at 11:22 a.m., the MDS coordinator stated she still had two care area assessments left to complete on the annual MDS assessment and that she had just finished them and submitted the MDS to CMS, indicating the assessment had not been completed and transmitted within the required timeframe. In a separate interview on 4/10/26 at 12:05 p.m., the Administrator reported that the facility did not have a policy regarding MDS transmissions, further demonstrating the lack of an established process to ensure that MDS data were encoded and transmitted to the State and CMS within the required time limits.
Inaccurate MDS Coding for Mental Health and PASARR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments accurately reflected residents’ clinical status for two residents. For one resident with diagnoses including bipolar disorder and anxiety, the Annual MDS dated 3/11/26 indicated the resident was not considered by the state Level II PASARR process to have a serious mental illness or intellectual disability/related condition, despite a Level II PASARR having been completed on 3/31/23. This discrepancy was identified through record review and confirmed in an interview with the MDS coordinator, who acknowledged that the MDS assessment did not accurately reflect the existing Level II PASARR information. For another resident with generalized anxiety disorder, major depressive disorder, and dementia, the Quarterly MDS dated 3/30/26 did not code anxiety as an active diagnosis. However, review of the MAR showed active orders as of 2/27/26 for Lorazepam, prescribed for generalized anxiety disorder, and the RAI manual specifies that active diagnoses should be identified using sources such as medication sheets and physician orders during the 7-day look-back period. In an interview, the MDS coordinator confirmed that the resident did have an active anxiety disorder diagnosis and that the MDS should have been coded “yes” for anxiety disorder but was incorrectly coded “no.” The Administrator and MDS coordinator also stated the facility did not have an MDS policy and relied on the RAI manual for completing assessments.
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